Assessment protocol for serial casting after botulinum toxin a injections to treat equinus gait

The effects of serial casting on lower limb function for children with Cerebral Palsy: a systematic review with meta-analysis

Background

Lower limb serial casting is commonly used therapeutically in paediatric clinical practice with some evidence to support its efficacy. This systematic review aimed to determine the effects of serial casting in isolation or combination with other therapies for the management of lower limb dysfunction in children with Cerebral Palsy (CP).

Methods

A systematic literature search was conducted in February 2019 across eight databases (PUBMED, EMBASE, CINAHL, PEDro, OTSeeker, Cochrane, Scopus and Proquest) using key terms ‘Cerebral Palsy’ and ‘serial casting’ and associated synonyms. A meta-synthesis and meta-analysis were undertaken when sufficient results were available showing the effect of serial casting on functional outcomes including: Ankle range of motion; neurological measures of hypertonicity and spasticity, functional gait measures and; gross motor function.

Results

Twenty-five articles from 3219 possible citations were included. Serial casting was found to be effective for: Improving ankle dorsiflexion (DF) passive range of motion (PROM) in the immediate to short-term, decreasing hypertonicity measured by Modified Ashworth Scale (MAS) in the short-term and, enhancing functional gait outcomes in the mid-term. Serial casting with or without botulinum toxin type-A (BTX-A) did not significantly affect gross motor capacity measured by Gross Motor Function Measure (GMFM). Serial casting with pharmacological intervention achieved significantly more DF PROM than serial casting alone (MD − 3.19 degrees; 95% CI − 5.76 to − 0.62; P = 0.01; I² = 0%), however the clinical importance of improving ankle DF PROM by an additional three degrees remains unclear.

Conclusions

Lower limb serial casting, improves several outcomes relevant to lower limb function supporting its clinical use for improving DF PROM, reducing hypertonicity and improving gait in children with CP. Further research using stronger methodological study designs, is indicated to explore long-term effects of serial casting on functional lower limb outcomes such as gross motor function in children with CP. Clinicians can use this information when developing individualised treatment plans for children who have CP during shared decision-making consultations.

Casting Protocols Following BoNT-A Injections to Treat Spastic Hypertonia of the Triceps Surae in Children with Cerebral Palsy and Equinus Gait: A Randomized Controlled Trial

AIM

To study the effects of single versus serial casting post-Botulinum toxin A (BoNT-A) injections on hypoextensibility of triceps surae in children, 2-7 years old, with cerebral palsy and equinus gait.

METHODS

A randomized, stratified, parallel, two-group trial was conducted at a pediatric health center with assessments at baseline, precast, postcast and, 1-, 2-, and 6-month follow-ups. One week following BoNT-A injections into triceps surae muscle, a single below-knee cast (n = 10) or 3 serial casts (n = 10) were applied for 3 weeks. Primary outcome measure was the Modified Tardieu Scale (MTS), secondary outcome measures were Modified Ashworth Scale (MAS), GAITRite™, Gross Motor Function Measure-66 (GMFM-66), and Pediatric Evaluation of Disability Inventory (PEDI).

RESULTS

Significant effects of time, but not group-by-time, were found for MTS R1 (P < 0.001), MTS R2 (P < 0.001), MAS (P = 0.001), GMFM-66 (P = 0.002), and PEDI (P < 0.001-0.009). One participant who received a single cast did not complete the 6-month assessment.

CONCLUSIONS

Magnitudes of improvements were similar using single or serial casting. If these findings are corroborated in a larger scale study, the recommendation of a single cast may be appropriate due to its greater convenience for families and clinicians.

Quantification of gait in children with mitochondrial disease

Mitochondrial disorders are multisystem conditions that can potentially affect gait in many ways. The aim of this study was to select the optimal protocol to quantify the spatiotemporal parameters of gait in ambulatory children with mitochondrial disorders based on feasibility, test-retest reliability, and the difference between patients and controls. Gait at self-selected pace was quantified in ambulatory children with a genetically confirmed primary mitochondrial disease using the GAITRite electronic walkway. Three protocols were tested: pre-exercise, post-exercise (after a 3-min walking test), and recovery. In 14 ambulatory patients, we showed good to perfect reliability for velocity, cadence, step length, step time, step time variability, and step width in the recovery condition. The difference between patients and 70 individually age- and gender matched healthy controls only became apparent in the post-exercise protocol. In conclusion, measuring spatiotemporal parameters of gait using the GAITRite in ambulatory children with mitochondrial disease is feasible and reliable for most of the parameters measured. When using gait analysis in future studies in children with mitochondrial disease, we advise i) to use an exercise test prior to the gait analysis, ii) to let children practice the test before the actual data collection, and iii) not to use symmetry parameters.

Quantitative evaluation for spasticity of calf muscle after botulinum toxin injection in patients with cerebral palsy: a pilot study

Background

Cerebral palsy (CP) is the most common pediatric disease to cause motor disability. Two common symptoms in CP are spasticity and contracture. If this occurred in the ankle plantar flexors of children with CP, it will impair their gait and active daily living profoundly. Most children with CP receive botulinum toxin type A (BoNT-A) injection to reduce muscle tone, but a knowledge gap exists in the understanding of changes of neural and non-neural components of spasticity after injection. The purpose of this study was to determine if our device for quantitative modified Tardieu approach (QMTA) is a valid method to assess spasticity of calf muscles after botulinum toxin injection.

Methods

In this study, we intended to develop a device for quantitative measurement of spasticity in calf muscles based on the modified Tardieu scale (MTS) and techniques of biomedical engineering. Our QMTA measures the angular displacement and resistance of stretched joint with a device that is light, portable and can be operated similar to conventional approaches for MTS. The static (R2), dynamic (R1) and R2-R1 angles derived from the reactive signals collected by the miniature sensors are used to represent the non-neural and neural components of stretched spastic muscles. Four children with CP were recruited to assess the change in spasticity in their gastrocnemius muscles before and 4 weeks after BoNT-A injection.

Results

A simulated ankle model validated the performance of our device in measuring joint displacement and estimating the angle of catch. Data from our participants with CP showed that R2 and R2-R1 improved significantly after BoNT-A administration. It indicates both neural and non-neural components of the spastic gastrocnemius muscles improved at four weeks after BoNT-A injection in children with CP.

Conclusion

Our device for QMTA can objectively measure the changes in spasticity of the gastrocnemius muscle in children with cerebral palsy after BoNT-A injection.

Measurement properties of gait-related outcomes in youth with neuromuscular diagnoses: a systematic review

BACKGROUND

Sound measurement properties of outcome tools are essential when evaluating outcomes of an intervention, in clinical practice and in research.

PURPOSE

The purpose of this study was to review the evidence on reliability, measurement error, and responsiveness of measures of gait function in children with neuromuscular diagnoses.

DATA SOURCES

The MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched up to June 15, 2012.

STUDY SELECTION

Studies evaluating reliability, measurement error, or responsiveness of measures of gait function in 1- to 18-year-old children and youth with neuromuscular diagnoses were included.

DATA EXTRACTION

Quality of the studies was independently rated by 2 raters using a modified COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. Studies with a fair quality rating or better were considered for best evidence synthesis.

DATA SYNTHESIS

Regarding the methodological quality, 32 out of 35 reliability studies, all of the 13 measurement error studies, and 5 out of 10 responsiveness studies were of fair or good quality. Best evidence synthesis revealed moderate to strong evidence for reliability for several measures in children and youth with cerebral palsy (CP) but was limited or unknown in other diagnoses. The Functional Mobility Scale (FMS) and the Gross Motor Function Measure (GMFM) dimension E showed limited positive evidence for responsiveness in children with CP, but it was unknown or controversial in other diagnoses. No information was reported on the minimal important change; thus, evidence on measurement error remained undetermined.

LIMITATIONS

As studies on validity were not included in the review, a comprehensive appraisal of the best available gait-related outcome measure per diagnosis is not possible.

CONCLUSIONS

There is moderate to strong evidence on reliability for several measures of gait function in children and youth with CP, whereas evidence on responsiveness exists only for the FMS and the GMFM dimension E.

Instrumented assessment of the effect of Botulinum Toxin-A in the medial hamstrings in children with cerebral palsy

This study examined the sensitivity of an instrumented spasticity assessment of the medial hamstrings (MEH) in children with cerebral palsy (CP). Nineteen children received Botulinum Toxin type A (BTX-A) injections in the MEH. Biomechanical (position and torque) and electrophysiological (surface electromyography, EMG) signals were integrated during manually-performed passive stretches of the MEH at low, medium and high velocity. Signals were examined at each velocity and between stretch velocities, and compared pre and post BTX-A (43 ± 16 days). Average change between pre and post BTX-A was interpreted in view of the minimal detectable change (MDC) calculated from previously published reliability results. Improvements greater than the MDC were found for nearly all EMG-parameters and for torque parameters at high velocity and at high versus low velocity (p<0.03), however large inter-subject variability was noted. Moderate correlations were found between the improvement in EMG and in torque (r=0.52, p<0.05). Biomechanical and electrophysiological parameters proved to be adequately sensitive to assess the response to treatment with BTX-A. Furthermore, studying both parameters at different velocities improves our understanding of spasticity and of the physiological effect of selective tone-reduction. This not only provides a clinical validation of the instrumented assessment, but also opens new avenues for further spasticity research.

The effect and complication of botulinum toxin type a injection with serial casting for the treatment of spastic equinus foot

Objective

To identify the effect of serial casting combined with Botulinum toxin type A (BTX-A) injection on spastic equinus foot.

Method

Twenty-nine children with cerebral palsy who had equinus foot were recruited from the outpatient clinic of Rehabilitation Medicine. The children were divided into 2 groups, one of which received serial casting after BTX-A injection, and the other which only received BTX-A injection. Serial casting started 3 weeks after the BTX-A injection, and was changed weekly for 3 times. Spasticity of the ankle joint was evaluated using the modified Ashworth scale (MAS), and the modified Tardieu scale (MTS). Gait pattern was measured using the physician's rating scale (PRS).

Results

The degree of ankle dorsiflexion and the MAS improved significantly until 12 weeks following the BTX-A injection in the serial casting group (p<0.001), while the BTX-A injection-only group improved until 6 weeks following injection (p<0.05). The combined group showed a significantly greater increase in the degree of dorsiflexion compared to the BTX-A injection-only group at post-injection weeks 6 and 12 (p<0.05). Three children (11.5%) suffered from foot ulcers as a complication caused by the serial casting.

Conclusion

Our study demonstrated that the effect of BTX-A injection with serial casting was superior and lasted longer than the effect of BTX-A injection only in patients with spastic equinus foot. We therefore recommend BTX-A injection with serial casting for the treatment of equinus foot. However, physicians must also consider the possible complications associated with serial casting.

Toxina botulínica e fisioterapia em crianças com paralisia cerebral espástica: revisão bibliográfica

INTRODUÇÃO: A paralisia cerebral (PC) é definida como uma condição neurológica não progressiva originada em razão de uma lesão no encéfalo imaturo que compromete os movimentos e a postura. A espasticidade está presente em 75% dos casos. Essa patologia tem incidência na população de aproximadamente 2 em cada 1.000 nascidos vivos e pode chegar a até 7 por 1.000 em países em desenvolvimento. O objetivo do estudo foi realizar uma revisão bibliográfica por meio da seleção e análise criteriosa de artigos científicos que relatem os efeitos da aplicação da toxina botulínica tipo A associada à fisioterapia em crianças com paralisia cerebral espástica. MATERIAIS E MÉTODOS: Foi realizada uma revisão bibliográfica nas bases de dados eletrônicas MEDLINE, LILACS e SciELO, no período de 1997 a 2009. Os descritores utilizados foram: "paralisia cerebral" e "espasticidade muscular", combinados com "toxina botulínica tipo A" e "fisioterapia". RESULTADOS: Somando-se todos os bancos de dados, um total de 50 artigos que continham os desfechos de interesse dessa revisão foram encontrados, no entanto, alguns artigos aparecem em mais de uma busca e em duplicidade de idioma. Então, 23 artigos foram utilizados neste estudo. DISCUSSÃO: Vários estudos demonstram que, para maior efetividade da toxina botulínica tipo A, esta deve ser associada a um programa fisioterapêutico que sempre deve considerar as etapas do desenvolvimento motor da criança. CONSIDERAÇÕES FINAIS: De acordo com a revisão bibliográfica apresentada, a TBA associada à fisioterapia para o controle da espasticidade se mostra bastante eficaz. Contudo, novas pesquisas acerca deste assunto são necessárias.

Ethics of involving children in health-related research: applying a decision-making framework to a clinical trial

PURPOSE

This paper explores ethical issues related to the involvement of children in health-related research through the application of a conceptual model (the Miller and Kenny framework) to a current clinical trial on casting protocols for equinus gait of children with cerebral palsy (CP).

SUMMARY OF KEY POINTS

The direct involvement of children in health-related research is important for maintaining and improving standards of paediatric clinical care. Ethical considerations around investigations involving this highly vulnerable population are complex, however, requiring the involvement of many levels of decision makers-government, research ethics boards (REBs), health care providers, parents, and children. The Miller and Kenny framework is useful in distinguishing these levels and heightening awareness of the complexities of the issues around engaging children in research. Considerations include the role of parents/caregivers in decision making, individual assessment of the child's decisional capacities, close attention to the child's context and life experience, provision of developmentally appropriate information about the research study, and careful assessment of dissent prior to withdrawing the child from the study.

RECOMMENDATIONS

Physical therapists involved in paediatric clinical practice and/or research must be knowledgeable about ethical principles, policies, and REB requirements. The Miller and Kenny framework is a helpful guide to clarify decision-making roles around children's participation in research.

Item bank development for a revised pediatric evaluation of disability inventory (PEDI)

The Pediatric Evaluation of Disability Inventory (PEDI) is a useful clinical and research assessment, but it has limitations in content, age range, and efficiency. The purpose of this article is to describe the development of the item bank for a new computer adaptive testing version of the PEDI (PEDI-CAT). An expanded item set and response options were reviewed by clinician experts and examined at parent and clinician focus groups. Eleven parents participated in 32 cognitive interviews to examine content, format, and comprehension of items and responses. A set of 76 self-care, 78 mobility, and 64 social function items with pictures and a four-point "Difficulty" scale were developed. The PEDI's Caregiver Assistance scale was replaced by a "Responsibility Scale" with 53 items. Content validity was established incorporating input from clinicians and parents. The new item bank covers a broad range of functional activities for children of all ages and abilities.

Short-term effects of combined serial casting and botulinum toxin injection for spastic equinus in ambulatory children with cerebral palsy

PURPOSE

The purpose of this paper is to test the hypothesis that combination therapy of serial cast and botulinum toxin type A (BTX-A) injection can further enhance the effects of a BTX-A injection in ambulant children with cerebral palsy (CP) who have an equinus foot.

MATERIALS AND METHODS

Children in group A (30 legs of 21 children) received a serial casting application after an injection of BTX-A, and children in group B (25 legs of 17 children) received only a BTX-A injection. Assessments were performed before the intervention and 1 month after the intervention.

RESULTS

After the intervention, there were significant improvements in tone, dynamic spasticity, and passive range of motion (ROM) in both groups. However, the changes were greater in group A than in group B. Dimension D (standing) in Gross Motor Function Measure (GMFM)-66 was significantly improved in group A but not in group B. On the other hand, there were no significant changes in dimension E (walking, running, jumping) in GMFM-66 in either group.

CONCLUSION

The results of our study suggest that a serial casting application after BTX-A injection can enhance the benefits of BTX-A injection in children with cerebral palsy.